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Overall Results of Ponseti Method Comparable to Surgery in Treatment of Clubfoot
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Posted on: 02/18/2010
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Clubfoot, a condition where a foot (or both feet) turn inward and downward, is a common orthopedic problem. In New Zealand, where the authors of this article are based, clubfeet are present in almost seven out of every 1,000 people who are of Polynesian descent, an ethnic group that makes up almost one quarter of the New Zealand population. The rate of clubfeet in Polynesian ethnic people is quite high compared with those of white European descent, who have an average of one clubfoot out of every thousand.
Traditionally, treatment of clubfoot in New Zealand has been with surgery, followed by casting below the knee. However, because there are so many clubfeet in New Zealand, researchers wanted to compare traditional surgery with manipulation and casting, called the Ponseti method. The study was supposed to be randomized, a procedure where the parents and the researchers don't know what type of treatment the children had, but only nine families agreed to the randomization; the others would not participate if they didn't know what treatment was being done. As a result, this was a study where the researchers looked back at the results, instead.
Researchers recruited 55 patients who had a total of 86 clubfeet. All patients had idiopathic clubfoot, which means that there was no known cause of the deformity. Twenty six patients (with 40 clubfeet) were treated with the Ponseti method and the remaining 29 patients (46 feet) were treated with surgery, followed by below-the-knee casts. The researchers gathered information on the children's sex, ethnicity, family history, the Pirani score (based on level of deformity), the number of casts used to treat each clubfoot, any complications, and if any revision (repeat) surgery was needed.
The children in the Ponseti group had casts applied to their clubfeet to manipulate their feet into the desired position. After the feet reached a certain angle, a small surgical procedure was performed to release (lengthen) the Achilles tendon, the tendon at the back of the ankle. Finally, the feet were then held in position by a cast for another three weeks, followed by bracing for three months full time and then for at least nine months worn while sleeping, including nap time. The total time for bracing was at least one year.
The children in the surgical group were also casted at first, but the casts were changed every week or two, depending on the child, as the foot moved position. At around six months old, each child had surgery, although the more severe clubfeet were generally operated on before the moderate or milder cases. During the surgery, the joints and muscles were moved and the Achilles tendon lengthened, as with the Ponseti group. In some cases, wires were inserted to hold the feet into place. After the surgery, the cast would be changed a couple of times. No bracing was done after the final cast was removed.
In gathering the data, the researchers found no difference between outcomes when looking at the two groups in regards to the children's sex, ethnicity, which foot was involved, age at first casting, initial Pirani score, or the number of years the children participated in follow-up. There was a significant difference between the groups with the number of casts used before Ponseti or surgery, with many more being used in the surgical group (5 versus 11) and in total, there were six compared to 13. Twenty four children had difficulties with their casts (poorly fitting, skin irritation) that required recasting.
Looking at the age of the children, those in the Ponseti group had, on average, the Achilles tendon procedure when they were 2.4 months, while the children in the surgical were, on average, 6.7 months when they had this procedure. Thirty eight of the feet in the Ponseti group had this procedure; 43 of the other group did.
Forty three of the children who had below-the-knee casts ended up having surgery, with 42 of them having a more extensive surgery. Eleven had the posterior released and the other 31 had the posteromedial (midline and back) released. Thirteen in this group needed repeat or revision surgeries. In the Ponseti group, 14 of the feet required a total of 15 surgeries (one revision), but 11 were minor procedures. Only four needed posterior (one) or posteromedial (three) releases. Both groups had two complications after surgery. In the surgery group, one child developed a urinary tract infection (UTI) and another developed cellulitis, infection in the skin. In the Ponseti group, one child developed an infection in the incision after having a posteromedial release and the other developed an infection after tendon surgery.
The average follow-up was 3.5 years for the Ponseti group and 3.8 years for the surgery group. Fifteen feet in the Ponseti group had recurrences, as did 14 in the surgery group. Only nine (35%) of the children in the Ponseti group wore their brace for the full year.
The authors pointed out that although the recurrence numbers were similar in both groups, the severity of the recurrence and the need for major surgery was different, with the surgery group requiring more than the Ponseti group. As well, with such a high rate of non-compliance with bracing for a full year in the Ponseti group, it was not possible to tell if the recurrences were due to an issue with the method or with the lack of proper bracing.
In all, the authors concluded that the Ponseti method was cost effective because of the similar results without the major surgery, however compliance was an issue.
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References:
Matthew A. Halanski, MD, et al. Ponseti Method Compared with Surgical Treatment of Clubfoot. In The Journal of Bone & Joint Surgery. February 2010. Vol. 92-A. No. 2. Pp. 270-278.
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